HFS 3745 (N-4-99) IL478-2471€¦ · 10 ICF 21,786 6,493 916 29,195 10 11 ICF/DD 11 IV. ACCOUNTING BASIS 12 SC 12 MODIFIED 13 DD 16 OR LESS 13 ACCRUAL X CASH* CASH* 14 TOTALS 30,134

FOR BHF USE IMPORTANT NOTICELL1 THIS AGENCY IS REQUESTING DISCLOSURE OF INFORMATION

THAT IS NECESSARY TO ACCOMPLISH THE STATUTORY2013 PURPOSE AS OUTLINED IN 210 ILCS 45/3-208. DISCLOSURE

STATE OF ILLINOIS OF THIS INFORMATION IS MANDATORY. FAILURE TO PROVIDEDEPARTMENT OF HEALTHCARE AND FAMILY SERVICES ANY INFORMATION ON OR BEFORE THE DUE DATE WILLFINANCIAL AND STATISTICAL REPORT (COST REPORT) RESULT IN CESSATION OF PROGRAM PAYMENTS. THIS FORM

FOR LONG-TERM CARE FACILITIES HAS BEEN APPROVED BY THE FORMS MANAGEMENT CENTER.(FISCAL YEAR 2013)

I. IDPH License ID Number: 0037358 II. CERTIFICATION BY AUTHORIZED FACILITY OFFICER

Facility Name: BRIDGEVIEW HEALTH CARE CTR I have examined the contents of the accompanying report to the

Address: 8100 S HARLEM AVENUE BRIDGEVIEW 60455 State of Illinois, for the period from 01/01/2013 to 12/31/2013Number City Zip Code and certify to the best of my knowledge and belief that the said contents

are true, accurate and complete statements in accordance withCounty: COOK applicable instructions. Declaration of preparer (other than provider)

is based on all information of which preparer has any knowledge.Telephone Number: ( 847 ) 679-8219 Fax # ( 847 ) 679-7377

Intentional misrepresentation or falsification of any informationHFS ID Number: in this cost report may be punishable by fine and/or imprisonment.

Date of Initial License for Current Owners: 10/02/91 (Signed)Officer or (Date)

Type of Ownership: Administrator (Type or Print Name) MARSHALL MAUERof Provider

VOLUNTARY,NON-PROFIT X PROPRIETARY GOVERNMENTAL (Title) TREASURERCharitable Corp. Individual StateTrust Partnership County (Signed) (SEE ATTACHED ACCOUNTANTS' REPORT)

IRS Exemption Code Corporation Other (Date)X "Sub-S" Corp. Paid (Print Name SANFORD BOKOR

Limited Liability Co. Preparer and Title) PRESIDENTTrustOther (Firm Name KRUPNICK, BOKOR, KAGDA & BROOKS, LTD

& Address) 8140 RIVER DRIVE, MORTON GROVE, IL 60053

(Telephone) ( 847 ) 675-3585 Fax #( 847 ) 675-5777 MAIL TO: BUREAU OF HEALTH FINANCE

In the event there are further questions about this report, please contact: ILLINOIS DEPT OF HEALTHCARE AND FAMILY SERVICESName:SANFORD BOKOR Telephone Number: ( 847 ) 675-3585 201 S. Grand Avenue East

Email Address: Springfield, IL 62763-0001 Phone # (217) 782-1630

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 2Facility Name & ID Number BRIDGEVIEW HEALTH CARE CTR # 0037358 Report Period Beginning: 01/01/2013 Ending: 12/31/2013

III. STATISTICAL DATA D. How many bed-hold days during this year were paid by the Department?A. Licensure/certification level(s) of care; enter number of beds/bed days, 0 (Do not include bed-hold days in Section B.) (must agree with license). Date of change in licensed beds

E. List all services provided by your facility for non-patients. 1 2 3 4 (E.g., day care, "meals on wheels", outpatient therapy)

NONE Beds at Licensed Beginning of Licensure Beds at End of Bed Days During F. Does the facility maintain a daily midnight census? YES Report Period Level of Care Report Period Report Period

G. Do pages 3 & 4 include expenses for services or1 97 Skilled (SNF) 97 35,405 1 investments not directly related to patient care?2 Skilled Pediatric (SNF/PED) 2 YES NO X3 49 Intermediate (ICF) 49 17,885 34 Intermediate/DD 4 H. Does the BALANCE SHEET (page 17) reflect any non-care assets?5 Sheltered Care (SC) 5 YES NO X6 ICF/DD 16 or Less 6

I. On what date did you start providing long term care at this location?7 146 TOTALS 146 53,290 7 Date started 10/2/91

J. Was the facility purchased or leased after January 1, 1978?B. Census-For the entire report period. YES Date NO X

1 2 3 4 5 Level of Care Patient Days by Level of Care and Primary Source of Payment K. Was the facility certified for Medicare during the reporting year?

Medicaid YES X NO If YES, enter numberRecipient Private Pay Other Total of beds certified 97 and days of care provided 5,021

8 SNF 8,348 2,353 6,037 16,738 8 9 SNF/PED 9 Medicare Intermediary WISCONSIN PHYSICIANS SERVICE10 ICF 21,786 6,493 916 29,195 1011 ICF/DD 11 IV. ACCOUNTING BASIS12 SC 12 MODIFIED13 DD 16 OR LESS 13 ACCRUAL X CASH* CASH*

14 TOTALS 30,134 8,846 6,953 45,933 14 Is your fiscal year identical to your tax year? YES X NO

C. Percent Occupancy. (Column 5, line 14 divided by total licensed Tax Year: 12/31/2013 Fiscal Year: 12/31/2013 bed days on line 7, column 4.) 86.19% * All facilities other than governmental must report on the accrual basis.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 3Facility Name & ID Number BRIDGEVIEW HEALTH CARE CTR # 0037358 Report Period Beginning: 01/01/2013 Ending: 12/31/2013V. COST CENTER EXPENSES (throughout the report, please round to the nearest dollar)

Costs Per General Ledger Reclass- Reclassified Adjust- Adjusted FOR BHF USE ONLY Operating Expenses Salary/Wage Supplies Other Total ification Total ments TotalA. General Services 1 2 3 4 5 6 7 8 9 10

1 Dietary 7,157 613,353 620,510 620,510 620,510 12 Food Purchase 3,041 3,041 3,041 (1,526) 1,515 23 Housekeeping 1,684 207,039 208,723 208,723 208,723 34 Laundry 11,212 133,080 144,292 144,292 144,292 45 Heat and Other Utilities 120,349 120,349 120,349 1,216 121,565 56 Maintenance 103,473 63,584 38,257 205,314 205,314 18,110 223,424 67 Other (specify):* 11,224 11,224 11,224 1,092 12,316 7

8 TOTAL General Services 103,473 86,678 1,123,302 1,313,453 1,313,453 18,892 1,332,345 8B. Health Care and Programs

9 Medical Director 2,100 2,100 2,100 2,100 910 Nursing and Medical Records 2,580,532 95,687 16,984 2,693,203 2,693,203 2,693,203 10

10a Therapy 494,153 8,596 502,749 502,749 502,749 10a11 Activities 339,795 18,450 816 359,061 359,061 359,061 1112 Social Services 1213 CNA Training 1314 Program Transportation 7,538 7,538 7,538 7,538 1415 Other (specify):* 15

16 TOTAL Health Care and Programs 3,414,480 122,733 27,438 3,564,651 3,564,651 3,564,651 16C. General Administration

17 Administrative 129,282 186,000 315,282 315,282 (26,544) 288,738 1718 Directors Fees 1819 Professional Services 80,175 80,175 80,175 (12,123) 68,052 1920 Dues, Fees, Subscriptions & Promotions 115,444 115,444 115,444 (87,512) 27,932 2021 Clerical & General Office Expenses 265,405 30,303 559,316 855,024 855,024 (421,717) 433,307 2122 Employee Benefits & Payroll Taxes 710,467 710,467 710,467 710,467 2223 Inservice Training & Education 15,952 15,952 15,952 15,952 2324 Travel and Seminar 969 969 2425 Other Admin. Staff Transportation 25,027 25,027 25,027 2,117 27,144 2526 Insurance-Prop.Liab.Malpractice 260,985 260,985 260,985 8,468 269,453 2627 Other (specify):* 145,000 145,000 145,000 (100,832) 44,168 27

28 TOTAL General Administration 394,687 30,303 2,098,366 2,523,356 2,523,356 (637,174) 1,886,182 28TOTAL Operating Expense

29 (sum of lines 8, 16 & 28) 3,912,640 239,714 3,249,106 7,401,460 7,401,460 (618,282) 6,783,178 29*Attach a schedule if more than one type of cost is included on this line, or if the total exceeds $1000.NOTE: Include a separate schedule detailing the reclassifications made in column 5. Be sure to include a detailed explanation of each reclassification.

HFS 3745 (N-4-99) IL478-2471

Facility Name & ID#: BRIDGEVIEW HEALTH CARE CTR #0037358 Report Period Beginning: 01/01/2013 Ending: 12/31/2013V.COST CENTER EXPENSES PAGE 3 COLUMN 3 OTHER

LINE SCHED REF TOTAL LINE SCHED REF TOTAL1 DIETARY 10 NURSING

DIETITIAN CONSULTANT XVIII B 35-2 0 CONTRACT NURSING XVIII C 53-2 REPAIRS & MAINTENANCE 200 LABORATORY & XRAY EXPENSE 0 CONTRACTED DIETARY SERVICES 613,153 613,353 PURCHASED SERVICES 0

3 HOUSEKEEPING 0 PSYCHO-SOCIAL CONSULTANT XVIII B __-2 0 CONTRACTED HOUSEKEEPING 207,039 RESTORATIVE NURSING CONSULTANTXVIII B 38-2 0 0 207,039 MEDICAL RECORDS CONSULTANT XVIII B 37-2 0

4 LAUNDRY PHARMACY CONSULTANT XVIII B 39-2 9,199 EQUIPMENT REPAIRS & MAINTENANCE 3,902 UTILIZATION REVIEW FEES XVIII B __-2 0 CONTRACTED LAUNDRY SERVICES 129,178 133,080 PHYSICIANS XVIII B __-2 0

5 HEAT & OTHER UTILITIES PSYCHIATRIC XVIII B __-2 0 GAS HEAT 38,936 RN CONSULTANT XVIII B 38-2 0 ELECTRICITY 47,873 SPECIAL CARE UNIT 7,785 WATER 33,540 0 16,984 CABLE TV - LOBBY 0 10a THERAPY 0 120,349 PHYSICAL THERAPY SERVICES 0

6 MAINTENANCE SPEECH THERAPY SERVICES 0 GROUNDS MAINTENANCE 9,219 OCCUPATIONAL THERAPY SERVICES 0 PAINTING & DECORATING 2,560 REHABILITATION CONSULTANT XVIII B __-2 0 BUILDING REPAIRS 0 PHYSICAL THERAPY CONSULTANT XVIII B 40-2 0 MAINTENANCE TRAVEL 0 OCCUPATIONAL THERAPY CONSULTA XVIII B 41-2 0 EQUIPMENT MAINTENANCE & REPAIR 14,045 RESPIRATORY THERAPY CONSULTAN XVIII B 42-2 0 ELEVATOR MAINTENANCE & REPAIR 7,763 SPEECH THERAPY CONSULTANT XVIII B 43-2 0 OUTSIDE LABOR 0 EXTERMINATING SERVICE 4,670 FIRE SERVICE 0 0

0 11 ACTIVITIES 0 CABLE TV - PATIENT ROOMS 0 0 ACTIVITY REHAB CONSULTANT XVIII B 44-2 816 0 38,257 0 816

7 OTHER 12 SOCIAL SERVICES SCAVENGER 11,224 SOCIAL REHABILITATION SERVICES 0 SECURITY SERVICE 0 SOCIAL REHABILITATION CONSULTAN XVIII B 45-2 0

0 SOCIAL WORKER XVIII B 45-2 00 11,224 0

9 MEDICAL DIRECTOR 13 NURSE AIDE TRAINING MEDICAL DIRECTOR FEES XVIII B 36-2 2,100 2,100 NURSE AIDE TRAINING COSTS XIII 0 0

HFS 3745 (N-4-99) IL478-2471

HFS 3745 (N-4-99) IL478-2471

Facility Name & ID Number BRIDGEVIEW HEALTH CARE CTR #0037358 Report Period Beginning: 01/01/2013 Ending: 12/31/2013V.COST CENTER EXPENSES PAGE 3 COLUMN 3 OTHER

LINE SCHED REF TOTAL LINE SCHED REF TOTAL14 PROGRAM TRANSPORTATION 22 EMPLOYEE BENEFITS & PAYROLL TAXES

PATIENT TRANSPORTATION 7,538 7,538 FICA TAXES XIX D 294,5580 UNEMPLOYMENT COMPENSATION XIX D 84,500

17 ADMINISTRATIVE 0 WORKERS COMPENSATION INSURANC XIX D 102,871 MANAGEMENT FEES XIX B 186,000 186,000 HOSPITALIZATION INSURANCE XIX D 192,381DIRECTORS FEES EMPLOYEE BENEFITS - OTHER XIX D 36,157

18 DIRECTORS FEES 0 0 EMPLOYEE PHYSICAL EXAMS XIX D 019 PROFESSIONAL SERVICES 0 INSURANCE - EXECUTIVE LIFE VI 21/XIX D 0

DATA PROCESSING XIX C 38,153 PENSION/PROFIT SHARING PLANS XIX D 0 ADMINISTRATIVE CONSULTANTS XIX C 0 CHICAGO HEAD TAX XIX D 0 PROFESSIONAL FEES XIX C 42,022 0 710,467

0 80,175 23 INSERVICE TRAINING & EDUCATION20 FEES,SUBSCRIPTIONS,PROMOTIONS EDUCATION & SEMINARS 15,952

ENTERTAINMENT & MARKETING VI 19 XIX F 0 15,952 ADV & PROMO-NON PATIENT RELATED VI 25 XIX F 83,165 24 TRAVEL & SEMINARS EMPLOYEE WANT ADS XIX F 8,950 EDUCATION & SEMINARS XIX G 0 CONTRIBUTIONS VI 20 XIX F 0 TRAVEL XIX G 0 DUES & SUBSCRIPTIONS XIX F 12,782 LICENSES & PERMITS XIX F 3,952 0 PUBLIC RELATIONS-PATIENT RELATED XIX F 0 25 ADMIN. STAFF TRANSPORTATION ADVERTISING-YELLOW PAGES VI 28 XIX F 0 TRANSPORTATION - STAFF 25,027 TRUST FEES / FRANCHISE TAX / ETC VI 17 XIX F 0 25,027 CONTRIBUTIONS - POLITICAL VI 20 XIX F 5,615 26 INSURANCE - PROP. LIAB & MALPRACTICE HEALTH CARE WORKER BACKGROUND CHEC XIX F 980 GENERAL INSURANCE 260,985 PATIENT BACKGROUND CHECKS XIX F 0

115,444 260,98521 CLERICAL & GENERAL OFFICE EXPENSES 0 27 OTHER

BANK CHARGES (INCLUDES NO OVERDRAFT CHARGES) 11,095 BAD DEBTS VI 24 145,000 EQUIPMENT REPAIR & MAINTENANCE 28,207 145,000 OUTSIDE CLERICAL SERVICES 497,700 PENALTIES / OVERDRAFT CHARGES VI 18 0 HOME OFFICE EXPENSE 0 THEFT & DAMAGE LOSS 0 GRAND TOTAL COLUMN 3 OTHER 3,249,106 TELEPHONE 22,314 MESSENGER SERVICE 0 0 559,316

HFS 3745 (N-4-99) IL478-2471

BRIDGEVIEW HEALTH CARE CTRSCHEDULES12/31/2013

EMPLOYEE MEAL RECLASSIFICATIONPAGE 3 SCHEDULE V COLUMN 5 LINES 2 AND 22

TOTAL FOOD PURCHASE 3,041LESS SALES TAX (1,526)NET FOOD 1,515

TOTAL PATIENT CENSUS 45,933TIMES 3 MEALS PER DAY 3TOTAL PATIENT MEALS 137,799

ADD # EMPLOYEE MEALS/DAY 0TIMES # DAYS 365TOTAL EMPLOYEE MEALS 0

PATIENT MEALS 137,799ADD EMPLOYEE MEALS 0TOTAL MEALS/YEAR 137,799

NET FOOD 1,515DIVIDE TOTAL MEALS/YEAR 137,799

COST PER MEAL 0.01TIMES EMPLOYEE MEALS 0EMPLOYEE MEAL RECLASSIFICATION 0

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 4Facility Name & ID Number BRIDGEVIEW HEALTH CARE CTR #0037358 Report Period Beginning: 01/01/2013 Ending: 12/31/2013

#V. COST CENTER EXPENSES (continued)

Cost Per General Ledger Reclass- Reclassified Adjust- Adjusted FOR BHF USE ONLY Capital Expense Salary/Wage Supplies Other Total ification Total ments TotalD. Ownership 1 2 3 4 5 6 7 8 9 10

30 Depreciation 104,101 104,101 104,101 159,974 264,075 3031 Amortization of Pre-Op. & Org. 3132 Interest 21,676 21,676 21,676 297,049 318,725 3233 Real Estate Taxes 391,663 391,663 391,663 4,694 396,357 3334 Rent-Facility & Grounds 489,240 489,240 489,240 (489,240) 3435 Rent-Equipment & Vehicles 8,328 8,328 8,328 10,821 19,149 3536 Other (specify):* 36

37 TOTAL Ownership 1,015,008 1,015,008 1,015,008 (16,702) 998,306 37 Ancillary ExpenseE. Special Cost Centers

38 Medically Necessary Transportation 3839 Ancillary Service Centers 138,787 1,870 140,657 140,657 140,657 3940 Barber and Beauty Shops 4041 Coffee and Gift Shops 4142 Provider Participation Fee 328,070 328,070 328,070 328,070 4243 Other (specify):* 43

44 TOTAL Special Cost Centers 138,787 329,940 468,727 468,727 468,727 44GRAND TOTAL COST

45 (sum of lines 29, 37 & 44) 3,912,640 378,501 4,594,054 8,885,195 8,885,195 (634,984) 8,250,211 45

*Attach a schedule if more than one type of cost is included on this line, or if the total exceeds $1000.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 5Facility Name & ID Number BRIDGEVIEW HEALTH CARE CTR # 0037358 Report Period Beginning: 01/01/2013 Ending: 12/31/2013VI. ADJUSTMENT DETAIL A. The expenses indicated below are non-allowable and should be adjusted out of Schedule V, pages 3 or 4 via column 7.

In column 2 below, reference the line on which the particular cost was included. (See instructions.) 1 2 3

Refer- BHF USE B. If there are expenses experienced by the facility which do not appear in the NON-ALLOWABLE EXPENSES Amount ence ONLY general ledger, they should be entered below.(See instructions.)

1 Day Care $ $ 1 1 22 Other Care for Outpatients 2 Amount Reference3 Governmental Sponsored Special Programs 3 31 Non-Paid Workers-Attach Schedule* $ 314 Non-Patient Meals 4 32 Donated Goods-Attach Schedule* 325 Telephone, TV & Radio in Resident Rooms 5 Amortization of Organization &6 Rented Facility Space 6 33 Pre-Operating Expense 337 Sale of Supplies to Non-Patients 7 Adjustments for Related Organization8 Laundry for Non-Patients 8 34 Costs (Schedule VII) (384,183) 349 Non-Straightline Depreciation 10,504 30 9 35 Other- Attach Schedule 35

10 Interest and Other Investment Income (708) 32 10 36 SUBTOTAL (B): (sum of lines 31-35) $ (384,183) 3611 Discounts, Allowances, Rebates & Refunds 11 (sum of SUBTOTALS12 Non-Working Officer's or Owner's Salary 12 37 TOTAL ADJUSTMENTS (A) and (B) ) $ (634,984) 3713 Sales Tax (1,526) 2 1314 Non-Care Related Interest 32 14 *These costs are only allowable if they are necessary to meet minimum15 Non-Care Related Owner's Transactions 15 licensing standards. Attach a schedule detailing the items included16 Personal Expenses (Including Transportation) 16 on these lines.17 Non-Care Related Fees 20 1718 Fines and Penalties 21 18 C. Are the following expenses included in Sections A to D of pages 319 Entertainment 20 19 and 4? If so, they should be reclassified into Section E. Please 20 Contributions (5,615) 20 20 reference the line on which they appear before reclassification.21 Owner or Key-Man Insurance 22 21 (See instructions.) 1 2 3 422 Special Legal Fees & Legal Retainers (14,731) 19 22 Yes No Amount Reference23 Malpractice Insurance for Individuals 23 38 Medically Necessary Transport. X $ 3824 Bad Debt (145,000) 27 24 39 3925 Fund Raising, Advertising and Promotional (83,165) 20 25 40 Gift and Coffee Shops X 40

Income Taxes and Illinois Personal 41 Barber and Beauty Shops X 4126 Property Replacement Tax 26 42 Laboratory and Radiology X 4227 CNA Training for Non-Employees 27 43 Prescription Drugs X 4328 Yellow Page Advertising 10 28 44 4429 Other-Attach Schedule (10,560) 29 45 Other-Attach Schedule 4530 SUBTOTAL (A): (Sum of lines 1-29) $ (250,801) $ 30 46 Other-Attach Schedule 46

47 TOTAL (C): (sum of lines 38-46) $ 47BHF USE ONLY

48 49 50 51 52

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 5ABRIDGEVIEW HEALTH CARE CTR

ID# 0037358Report Period Beginning: 01/01/2013

Ending: 12/31/2013Sch. V Line

NON-ALLOWABLE EXPENSES Amount Reference1 MARKETING SALARY $ (10,160) 21 12 MARKETING TRAVEL (400) 25 23 34 45 56 67 78 89 9

10 1011 1112 1213 1314 1415 1516 1617 1718 1819 1920 2021 2122 2223 2324 2425 2526 2627 2728 2829 2930 3031 3132 32

HFS 3745 (N-4-99) IL478-2471

33 3334 3435 3536 3637 3738 3839 3940 4041 4142 4243 4344 4445 4546 4647 4748 4849 Total (10,560) 49

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Summary AFacility Name & ID Number BRIDGEVIEW HEALTH CARE CTR # 0037358 Report Period Beginning: 01/01/2013 Ending: 12/31/2013SUMMARY OF PAGES 5, 5A, 6, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H AND 6I

SUMMARY Operating Expenses PAGES PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE TOTALSA. General Services 5 & 5A 6 6A 6B 6C 6D 6E 6F 6G 6H 6I (to Sch V, col.7)

1 Dietary 0 0 0 0 0 0 0 0 0 0 0 0 12 Food Purchase (1,526) 0 0 0 0 0 0 0 0 0 0 (1,526) 23 Housekeeping 0 0 0 0 0 0 0 0 0 0 0 0 34 Laundry 0 0 0 0 0 0 0 0 0 0 0 0 45 Heat and Other Utilities 0 0 1,216 0 0 0 0 0 0 0 0 1,216 56 Maintenance 0 0 10,094 8,016 0 0 0 0 0 0 0 18,110 67 Other (specify):* 0 0 245 0 847 0 0 0 0 0 0 1,092 78 TOTAL General Services (1,526) 0 11,555 8,016 847 0 0 0 0 0 0 18,892 8

B. Health Care and Programs9 Medical Director 0 0 0 0 0 0 0 0 0 0 0 0 9

10 Nursing and Medical Records 0 0 0 0 0 0 0 0 0 0 0 0 10 10a Therapy 0 0 0 0 0 0 0 0 0 0 0 0 10a11 Activities 0 0 0 0 0 0 0 0 0 0 0 0 1112 Social Services 0 0 0 0 0 0 0 0 0 0 0 0 1213 CNA Training 0 0 0 0 0 0 0 0 0 0 0 0 1314 Program Transportation 0 0 0 0 0 0 0 0 0 0 0 0 1415 Other (specify):* 0 0 0 0 0 0 0 0 0 0 0 0 15

16 TOTAL Health Care and Programs 0 0 0 0 0 0 0 0 0 0 0 0 16C. General Administration

17 Administrative 0 (186,000) 0 159,456 0 0 0 0 0 0 0 (26,544) 1718 Directors Fees 0 0 0 0 0 0 0 0 0 0 0 0 1819 Professional Services (14,731) 0 2,608 0 0 0 0 0 0 0 0 (12,123) 1920 Fees, Subscriptions & Promotions (88,780) 0 1,268 0 0 0 0 0 0 0 0 (87,512) 2021 Clerical & General Office Expenses (10,160) (497,700) 75,249 10,894 0 0 0 0 0 0 0 (421,717) 2122 Employee Benefits & Payroll Taxes 0 0 0 0 0 0 0 0 0 0 0 0 2223 Inservice Training & Education 0 0 0 0 0 0 0 0 0 0 0 0 2324 Travel and Seminar 0 0 969 0 0 0 0 0 0 0 0 969 2425 Other Admin. Staff Transportation (400) 0 2,517 0 0 0 0 0 0 0 0 2,117 2526 Insurance-Prop.Liab.Malpractice 0 7,421 1,047 0 0 0 0 0 0 0 0 8,468 2627 Other (specify):* (145,000) 0 14,057 0 30,111 0 0 0 0 0 0 (100,832) 27

28 TOTAL General Administration (259,071) (676,279) 97,715 170,350 30,111 0 0 0 0 0 0 (637,174) 28TOTAL Operating Expense

29 (sum of lines 8,16 & 28) (260,597) (676,279) 109,270 178,366 30,958 0 0 0 0 0 0 (618,282) 29

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Summary BFacility Name & ID Number BRIDGEVIEW HEALTH CARE CTR # 0037358 Report Period Beginning: 01/01/2013 Ending: 12/31/2013

SUMMARY OF PAGES 5, 5A, 6, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H AND 6I

SUMMARY Capital Expense PAGES PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE TOTALSD. Ownership 5 & 5A 6 6A 6B 6C 6D 6E 6F 6G 6H 6I (to Sch V, col.7)

30 Depreciation 10,504 147,113 2,357 0 0 0 0 0 0 0 0 159,974 3031 Amortization of Pre-Op. & Org. 0 0 0 0 0 0 0 0 0 0 0 0 3132 Interest (708) 294,024 3,733 0 0 0 0 0 0 0 0 297,049 3233 Real Estate Taxes 0 0 4,694 0 0 0 0 0 0 0 0 4,694 3334 Rent-Facility & Grounds 0 (489,240) 0 0 0 0 0 0 0 0 0 (489,240) 3435 Rent-Equipment & Vehicles 0 0 10,821 0 0 0 0 0 0 0 0 10,821 3536 Other (specify):* 0 0 0 0 0 0 0 0 0 0 0 0 36

37 TOTAL Ownership 9,796 (48,103) 21,605 0 0 0 0 0 0 0 0 (16,702) 37 Ancillary ExpenseE. Special Cost Centers

38 Medically Necessary Transportation 0 0 0 0 0 0 0 0 0 0 0 0 3839 Ancillary Service Centers 0 0 0 0 0 0 0 0 0 0 0 0 3940 Barber and Beauty Shops 0 0 0 0 0 0 0 0 0 0 0 0 4041 Coffee and Gift Shops 0 0 0 0 0 0 0 0 0 0 0 0 4142 Provider Participation Fee 0 0 0 0 0 0 0 0 0 0 0 0 4243 Other (specify):* 0 0 0 0 0 0 0 0 0 0 0 0 43

44 TOTAL Special Cost Centers 0 0 0 0 0 0 0 0 0 0 0 0 44GRAND TOTAL COST

45 (sum of lines 29, 37 & 44) (250,801) (724,382) 130,875 178,366 30,958 0 0 0 0 0 0 (634,984) 45

HFS 3745 (N-4-99) IL478-2471


VII. RELATED PARTIES A. Enter below the names of ALL owners and related organizations (parties) as defined in the instructions. Use Page 6-Supplemental as necessary.

1 2 3 OWNERS RELATED NURSING HOMES OTHER RELATED BUSINESS ENTITIES

Name Ownership % Name City Name City Type of BusinessSEE PAGE 6 SUPP SEE PAGE 6 SUPP SEE PAGE 6 SUPP

B. Are any costs included in this report which are a result of transactions with related organizations? This includes rent,management fees, purchase of supplies, and so forth. X YES NO

If yes, costs incurred as a result of transactions with related organizations must be fully itemized in accordance withthe instructions for determining costs as specified for this form.1 2 3 Cost Per General Ledger 4 5 Cost to Related Organization 6 7 8 Difference:

Percent Operating Cost Adjustments for Schedule V Line Item Amount Name of Related Organization of of Related Related Organization

Ownership Organization Costs (7 minus 4)1 V 17 MANAGEMENT FEES $ 186,000 DYNAMIC HEALTHCARE $ $ (186,000) 12 V 21 BOOKKEEPING SERVICES 497,700 " " (497,700) 23 V 34 V 45 V 56 V 67 V 34 RENT 489,240 BRIDGEVIEW ASSOCIATES LLC (489,240) 78 V 30 DEPRECIATION " " 147,113 147,113 89 V 32 AMORTIZATION " " 1,865 1,865 9

10 V 32 INTEREST " " 292,159 292,159 1011 V 26 PROPERTY/BOILER INSURANCE " " 7,421 7,421 1112 V 1213 V 1314 Total $ 1,172,940 $ 448,558 $ * (724,382) 14

* Total must agree with the amount recorded on line 34 of Schedule VI.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 6AFacility Name & ID Number BRIDGEVIEW HEALTH CARE CTR # 0037358 Report Period Beginning: 01/01/2013 Ending: 12/31/2013

VII. RELATED PARTIES (continued) B. Are any costs included in this report which are a result of transactions with related organizations? This includes rent,

management fees, purchase of supplies, and so forth. X YES NO



Ownership Organization Costs (7 minus 4)15 V 5 UTILITIES $ DYNAMIC HEALTHCARE CONSULTANTS $ 1,216 $ 1,216 1516 V 6 REPAIR & MAINT. " " 10,094 10,094 1617 V 7 EMP BEN-GEN SERV " " 245 245 1718 V 19 PROFESSIONAL FEES " " 2,608 2,608 1819 V 20 DUES AND SUBSCRIPTION " " 1,268 1,268 1920 V 21 CLERICAL & GENERAL " " 75,249 75,249 2021 V 24 SEMINARS AND TRAVEL " " 969 969 2122 V 25 AUTO EXPENSE " " 2,517 2,517 2223 V 26 INSURANCE " " 1,047 1,047 2324 V 27 EMP. BEN. - GEN, ADMIN. " " 14,057 14,057 2425 V 30 DEPRECIATION " " 2,357 2,357 2526 V 32 INTEREST " " 3,733 3,733 2627 V 33 REAL ESTATE TAXES " " 4,694 4,694 2728 V 35 EQUIPMENT RENTAL " " 10,734 10,734 2829 V 35 EQUIPMENT RENTAL " " 87 87 2930 V 3031 V 3132 V 3233 V 3334 V 3435 V 3536 V 3637 V 3738 V 38

39 Total $ $ 130,875 $ * 130,875 39


HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 6BFacility Name & ID Number BRIDGEVIEW HEALTH CARE CTR # 0037358 Report Period Beginning: 01/01/2013 Ending: 12/31/2013





Ownership Organization Costs (7 minus 4)15 V 6 MAINT COMP - D NEHMER $ DYNAMIC HEALTHCARE CONSULTANTS $ 8,016 $ 8,016 1516 V 17 ADMIN COMP - M MAUER " " 23,765 23,765 1617 V 17 ADMIN COMP - M AARON " " 26,936 26,936 1718 V 17 ADMIN COMP - F AARON " " 2,500 2,500 1819 V 17 ADMIN COMP - D AARON " " 22,291 22,291 1920 V 17 ADMIN COMP - S GOLDSTEIN " " 2021 V 17 ADMIN COMP - S HARAMARAS " " 2122 V 17 ADMIN COMP - D KUFTA " " 21,272 21,272 2223 V 17 ADMIN COMP - HOWARD ALTER " " 2324 V 17 ADMIN COMP - NON OWNER - V DAVIS " " 14,038 14,038 2425 V 17 ADMIN COMP - NON OWNER - VAR " " 24,461 24,461 2526 V 17 ADMIN COMP - NON OWNER - CFO " " 24,193 24,193 2627 V 21 CLERICAL COMP - S AARON " " 10,293 10,293 2728 V 21 CLERICAL COMP - E MARYLES 601 601 2829 V 2930 V 3031 V 3132 V 3233 V 3334 V 3435 V 3536 V 3637 V 3738 V 38

39 Total $ $ 178,366 $ * 178,366 39


HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 6CFacility Name & ID Number BRIDGEVIEW HEALTH CARE CTR # 0037358 Report Period Beginning: 01/01/2013 Ending: 12/31/2013





Ownership Organization Costs (7 minus 4)15 V 7 EMP BEN - D NEHMER $ DYNAMIC HEALTHCARE CONSULTANTS $ 847 $ 847 1516 V 27 EMP BEN - M MAUER " " 1,303 1,303 1617 V 27 EMP BEN - M AARON " " 1,896 1,896 1718 V 27 EMP BEN - F AARON " " 7,537 7,537 1819 V 27 EMP BEN - D AARON " " 1,806 1,806 1920 V 27 EMP BEN - S GOLDSTEIN " " 2021 V 27 EMP BEN - S HARAMARAS " " 2122 V 27 EMP BEN - D KUFTA " " 1,498 1,498 2223 V 27 EMP BEN - HOWARD ALTER " " 2324 V 27 EMP BEN - V DAVIS " " 3,615 3,615 2425 V 27 EMP BEN - NON OWNER " " 7,424 7,424 2526 V 27 EMP BEN - NON OWNER - CFO " " 2,937 2,937 2627 V 27 EMP BEN - S AARON " " 2,046 2,046 2728 V 27 EMP BEN - E MARYLES 49 49 2829 V 2930 V 3031 V 3132 V 3233 V 3334 V 3435 V 3536 V 3637 V 3738 V 38

39 Total $ $ 30,958 $ * 30,958 39


HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 6-SupplementalFacility Name & ID Number BRIDGEVIEW HEALTH CARE CTR # 0037358 Report Period Beginning: 01/01/2013 Ending: 12/31/2013

VII. RELATED PARTIES A. (Continued) Enter below the names of ALL owners and related organizations (parties) as defined in the instructions.

1 2 3 OWNERS RELATED NURSING HOMES OTHER RELATED BUSINESS ENTITIES

Name Ownership % Name City Name City Type of Business

1 RAJCHENBACH FAMILY TRUST 18.75 BRADLEY BRADLEY BRIDGEVIEW ASSOCIATES LLC BUILDING CO 12 MAURICE AARON 19.74 GROSS POINTE MANOR LLC NILES DYNAMIC HEALTH SKOKIE BOOKKEEPING/C 23 MARSHALL MAUER 12.83 OTTAWA PAVILION LTD OTTAWA SEASONS HOSPICE PARK RIDGE HOSPICE 34 FRED AARON 7.89 PARK RIDGE CARE CENTER LTD PARK RIDGE 45 SHIMON GOLDSTEIN 3.94 STERLING PAVILION LTD STERLING 56 SHARON AARON .41 WARREN PARK HEALTH AND LIVING CENCHICAGO 67 CHANA MAUER-RAY 4.44 WATERFRONT TERRACE INC CHICAGO 78 DENNIS NEHMER .41 WINDMILL NURSING PAVILION LTD SOUTH HOLLAND 89 DIANA KUFTA .41 WOODBRIDGE NURSING PAVILION LTD CHICAGO 910 10

HFS 3745 (N-4-99) IL478-2471

10 ESTHER MARYLES 4.44 WOODRIDGE SUPPORTING LIVING RESID GALESBURG 1011 HOWIE & SUSIE ALTER .82 WOODRIDGE SUPPORTING LIVING RESID GENESEO 1112 SUE KOPLIN HARAMARAS .41 WOODRIDGE SUPPORTIVE LIVING RESIDEPONTIAC 1213 SYLVIA AARON .16 1314 FRANCES MAUER 6.58 1415 MARK HOLLANDER DISCRETIONARY6.25 1516 SHARON HOLLANDER DISCRETIONA 6.25 1617 FEIGE KNOBEL DISCRETIONARY TRU6.25 1718 1819 1920 2021 2122 2223 2324 2425 2526 2627 2728 2828 2829 2930 30

HFS 3745 (N-4-99) IL478-2471


VII. RELATED PARTIES (continued)C. Statement of Compensation and Other Payments to Owners, Relatives and Members of Board of Directors. NOTE: ALL owners ( even those with less than 5% ownership) and their relatives who receive any type of compensation from this home must be listed on this schedule.

1 2 3 4 5 6 7 8Average Hours Per Work

Compensation Week Devoted to this Compensation Included Schedule V.Received Facility and % of Total in Costs for this Line &

Ownership From Other Work Week Reporting Period** ColumnName Title Function Interest Nursing Homes* Hours Percent Description Amount Reference

1 MARSHALL MAUER SHAREHOLDER ADMINISTRATIVE 4.75 11.88 SALARY $ 23,765 17-7 12 MAURY AARON SHAREHOLDER ADMINISTRATIVE 5.39 10.77 SALARY 26,936 17-7 23 SHARON AARON SHAREHOLDER CLERICAL 4.75 11.88 SALARY 10,293 21-7 34 FRED AARON SHAREHOLDER ADMINISTRATIVE 9 SALARY 37,500 17-1 45 FRED AARON SHAREHOLDER ADMINISTRATIVE SALARY 2,500 17-7 56 DIANIA KUFTA SHAREHOLDER ADMINISTRATIVE 6.73 13.47 SALARY 21,272 17-7 67 DENNIS NEHMER SHAREHOLDER MAINTENANCE 5.39 13.47 SALARY 8,016 6-7 78 ESTHER MARYLES SHAREHOLDER CLERICAL 0.33 1.19 SALARY 601 21-7 89 DANIEL AARON ADMINISTRATIVE 14.79 36.99 SALARY 22,291 17-7 9

10 1011 1112 1213 TOTAL $ 153,174 13

* If the owner(s) of this facility or any other related parties listed above have received compensation from other nursing homes, attach a schedule detailing the name(s)of the home(s) as well as the amount paid. THIS AMOUNT MUST AGREE TO THE AMOUNTS CLAIMED ON THE THE OTHER NURSING HOMES' COST REPORTS.

** This must include all forms of compensation paid by related entities and allocated to Schedule V of this report (i.e., management fees).FAILURE TO PROPERLY COMPLETE THIS SCHEDULE INDICATING ALL FORMS OF COMPENSATION RECEIVED FROM THIS HOME,ALL OTHER NURSING HOMES AND MANAGEMENT COMPANIES MAY RESULT IN THE DISALLOWANCE OF SUCH COMPENSATION

HFS 3745 (N-4-99) IL478-2471


VIII. ALLOCATION OF INDIRECT COSTS Name of Related Organization DYNAMIC HEALTH CARE CONSULTANTS

A. Are there any costs included in this report which were derived from allocations of central office Street Address 3359 W MAIN STREET or parent organization costs? (See instructions.) YES X NO City / State / Zip Code SKOKIE, IL 60076

Phone Number ( 847) 679-8219 B. Show the allocation of costs below. If necessary, please attach worksheets. Fax Number ( 847) 679-7377

1 2 3 4 5 6 7 8 9Schedule V Unit of Allocation Number of Total Indirect Amount of Salary

Line (i.e.,Days, Direct Cost, Subunits Being Cost Being Cost Contained Facility AllocationReference Item Square Feet) Total Units Allocated Among Allocated in Column 6 Units (col.8/col.4)x col.6

1 5 UTILITIES PATIENT DAYS 407,371 12 $ 10,786 $ 45,933 $ 1,216 12 6 REPAIR & MAINT. PATIENT DAYS 407,371 12 89,523 37,553 45,933 10,094 23 7 EMP BEN-GEN SERV PATIENT DAYS 407,371 12 2,175 45,933 245 34 19 PROFESSIONAL FEES PATIENT DAYS 407,371 12 23,130 45,933 2,608 45 20 DUES AND SUBSCRIPTION PATIENT DAYS 407,371 12 11,247 45,933 1,268 56 21 CLERICAL & GENERAL PATIENT DAYS 407,371 12 667,372 493,233 45,933 75,249 67 24 SEMINARS AND TRAVEL PATIENT DAYS 407,371 12 8,593 45,933 969 78 25 AUTO EXPENSE PATIENT DAYS 407,371 12 22,321 45,933 2,517 89 26 INSURANCE PATIENT DAYS 407,371 12 9,284 45,933 1,047 9

10 27 EMP. BEN. - GEN, ADMIN. PATIENT DAYS 407,371 12 124,673 45,933 14,057 1011 30 DEPRECIATION PATIENT DAYS 407,371 12 20,906 45,933 2,357 1112 32 INTEREST PATIENT DAYS 407,371 12 33,103 45,933 3,733 1213 33 REAL ESTATE TAXES PATIENT DAYS 407,371 12 41,631 45,933 4,694 1314 35 EQUIPMENT RENTAL PATIENT DAYS 407,371 12 95,202 45,933 10,734 1415 35 EQUIPMENT RENTAL PATIENT DAYS 407,371 12 770 45,933 87 1516 1617 1718 1819 1920 2021 2122 2223 2324 2425 TOTALS $ 1,160,716 $ 530,786 $ 130,875 25

HFS 3745 (N-4-99) IL478-2471







1 6 MAINT COMP - D NEHMER WGHTD AVG HOURS 40 9 $ 59,522 $ 59,522 5 $ 8,016 12 17 ADMIN COMP - M MAUER WGHTD AVG HOURS 40 11 200,000 200,000 5 23,765 23 17 ADMIN COMP - M AARON WGHTD AVG HOURS 40 9 200,000 200,000 5 26,936 34 17 ADMIN COMP - F AARON WGHTD AVG HOURS 45 5 12,500 12,500 9 2,500 45 17 ADMIN COMP - D AARON WGHTD AVG HOURS 40 3 60,271 60,271 15 22,291 56 17 ADMIN COMP - S GOLDSTEIN WGHTD AVG HOURS 40 2 90,400 90,400 67 17 ADMIN COMP - S HARAMARAS WGHTD AVG HOURS 30 4 75,864 75,862 78 17 ADMIN COMP - D KUFTA WGHTD AVG HOURS 50 9 158,070 158,070 7 21,272 89 17 ADMIN COMP - HOWARD ALTER WGHTD AVG HOURS 40 1 12,000 12,000 9

10 17 ADMIN COMP - NON OWNER - V DWGHTD AVG HOURS 40 11 118,147 118,147 5 14,038 1011 17 ADMIN COMP - NON OWNER - VAWGHTD AVG HOURS 45 9 181,559 181,559 6 24,461 1112 17 ADMIN COMP - NON OWNER - CFWGHTD AVG HOURS 40 11 203,618 203,618 5 24,193 1213 21 CLERICAL COMP - S AARON WGHTD AVG HOURS 40 11 86,700 86,700 5 10,293 1314 21 CLERICAL COMP - E MARYLES WGHTD AVG HOURS 28 12 50,541 50,541 0 601 1415 1516 1617 1718 1819 1920 2021 2122 2223 2324 2425 TOTALS $ 1,509,192 $ 1,509,190 $ 178,366 25

HFS 3745 (N-4-99) IL478-2471







1 7 EMP BEN - D NEHMER WGHTD AVG HOURS 40 9 $ 6,291 $ 5 $ 847 12 27 EMP BEN - M MAUER WGHTD AVG HOURS 40 11 10,970 5 1,303 23 27 EMP BEN - M AARON WGHTD AVG HOURS 40 9 14,077 5 1,896 34 27 EMP BEN - F AARON WGHTD AVG HOURS 45 5 37,685 9 7,537 45 27 EMP BEN - D AARON WGHTD AVG HOURS 40 3 4,884 15 1,806 56 27 EMP BEN - S GOLDSTEIN WGHTD AVG HOURS 40 2 41,051 67 27 EMP BEN - S HARAMARAS WGHTD AVG HOURS 30 4 25,938 78 27 EMP BEN - D KUFTA WGHTD AVG HOURS 50 9 11,132 7 1,498 89 27 EMP BEN - HOWARD ALTER WGHTD AVG HOURS 40 1 1,080 9

10 27 EMP BEN - V DAVIS WGHTD AVG HOURS 40 11 30,426 5 3,615 1011 27 EMP BEN - NON OWNER WGHTD AVG HOURS 45 9 55,102 6 7,424 1112 27 EMP BEN - NON OWNER - CFO WGHTD AVG HOURS 40 11 24,720 5 2,937 1213 27 EMP BEN - S AARON WGHTD AVG HOURS 40 11 17,233 5 2,046 1314 27 EMP BEN - E MARYLES WGHTD AVG HOURS 28 12 4,119 0 49 1415 1516 1617 1718 1819 1920 2021 2122 2223 2324 2425 TOTALS $ 284,708 $ $ 30,958 25

HFS 3745 (N-4-99) IL478-2471


IX. INTEREST EXPENSE AND REAL ESTATE TAX EXPENSE A. Interest: (Complete details must be provided for each loan - attach a separate schedule if necessary.)

1 2 3 4 5 6 7 8 9 10Reporting

Monthly Maturity Interest PeriodName of Lender Related** Purpose of Loan Payment Date of Amount of Note Date Rate Interest

YES NO Required Note Original Balance (4 Digits) ExpenseA. Directly Facility Related Long-Term

1 CAMBRIDGE X MORTGAGE $49,218.18 $ 5,722,000 $ 5,257,117 10/41 5.8500 $ 292,159 12 23 34 45 5

Working Capital6 BANK LEUMI X WORKING CAPITAL 750,000 17,673 67 PHARMACY X AP FINANCING 46,932 4,003 78 8

9 TOTAL Facility Related $49,218.18 $ 5,722,000 $ 6,054,049 $ 313,835 9B. Non-Facility Related*

10 1011 1112 1213 13

14 TOTAL Non-Facility Related $ $ $ 14

15 TOTALS (line 9+line14) $ 5,722,000 $ 6,054,049 $ 313,835 15

16) Please indicate the total amount of mortgage insurance expense and the location of this expense on Sch. V. $ N/A Line # 36

* Any interest expense reported in this section should be adjusted out on page 5, line 14 and, consequently, page 4, col. 7.(See instructions.)

** If there is ANY overlap in ownership between the facility and the lender, this must be indicated in column 2.(See instructions.)

HFS 3745 (N-4-99) IL478-2471


IX. INTEREST EXPENSE AND REAL ESTATE TAX EXPENSE (continued) B. Real Estate Taxes

Important, please see the next worksheet, "RE_Tax". The real estate tax 1. Real Estate Tax accrual used on 2012 report. statement and bill must accompany the cost report. $ 345,000 1

2. Real Estate Taxes paid during the year: (Indicate the tax year to which this payment applies. If payment covers more than one year, detail below.) $ 364,663 2

3. Under or (over) accrual (line 2 minus line 1). $ 19,663 3

4. Real Estate Tax accrual used for 2013 report. (Detail and explain your calculation of this accrual on the lines below.) $ 372,000 4

5. Direct costs of an appeal of tax assessments which has NOT been included in professional fees or other general operating costs on Schedule V, sections A, B or C. (Describe appeal cost below. Attach copies of invoices to support the cost and a copy of the appeal filed with the county.) $ 5

6. Subtract a refund of real estate taxes. You must offset the full amount of any direct appeal costs classified as a real estate tax cost plus one-half of any remaining refund. TOTAL REFUND $ For Tax Year. (Attach a copy of the real estate tax appeal board's decision.) $ 6

7. Real Estate Tax expense reported on Schedule V, line 33. This should be a combination of lines 3 thru 6. $ 391,663 7

Real Estate Tax History:

Real Estate Tax Bill for Calendar Year: 2008 204,234 8 FOR BHF USE ONLY2009 239,768 92010 257,629 10 13 FROM R. E. TAX STATEMENT FOR 2012 $ 132011 338,246 112012 364,663 12 14 PLUS APPEAL COST FROM LINE 5 $ 14

THE CURRENT YEAR REAL ESTATE TAX ACCRUAL IS BASEDON ~ 101% OF THE PRIOR YEAR REAL ESTATE TAX BILL 15 LESS REFUND FROM LINE 6 $ 15THE PAYMENT ON LINE 2 APPLIES TO THE 2012 TAX BILL.

16 AMOUNT TO USE FOR RATE CALCULATION $ 16

NOTES: 1. Please indicate a negative number by use of brackets( ). Deduct any overaccrual of taxes from prior year.

2. If facility is a non-profit which pays real estate taxes, you must attach a denial of an application for real estate tax exemption unless the building is rented from a for-profit entity. This denial must be no more than four years old at the time the cost report is filed.

HFS 3745 (N-4-99) IL478-2471

2012 LONG TERM CARE REAL ESTATE TAX STATEMENTFACILITY NAME BRIDGEVIEW HEALTH CARE CTR COUNTY COOK

FACILITY IDPH LICENSE NUMBER 0037358

CONTACT PERSON REGARDING THIS REPORT SANFORD BOKOR

TELEPHONE ( 847 ) 675-3585 FAX #: ( 847 ) 675-5777

A. Summary of Real Estate Tax Cost

Enter the tax index number and real estate tax assessed for 2012 on the lines provided below. Enter only the portion of thecost that applies to the operation of the nursing home in Column D. Real estate tax applicable to any portion of the nursinghome property which is vacant, rented to other organizations, or used for purposes other than long term care must not beentered in Column D. Do not include cost for any period other than calendar year 2012.

(A) (B) (C) (D)Tax

Applicable toTax Index Number Property Description Total Tax Nursing Home

1. 18-36-214-061-0000 NURSING HOME $ 364,662.68 $ 364,662.682. $ $3. $ $4. $ $5. $ $6. $ $7. $ $8. $ $9. $ $10. $ $

TOTALS $ 364,662.68 $ 364,662.68

B. Real Estate Tax Cost Allocations

HFS 3745 (N-4-99) IL478-2471

Does any portion of the tax bill apply to more than one nursing home, vacant property, or property which is not directlyused for nursing home services? YES X NO

If YES, attach an explanation and a schedule which shows the calculation of the cost allocated to the nursing home.(Generally the real estate tax cost must be allocated to the nursing home based upon sq. ft. of space used.)

C. Tax Bills

Attach a copy of the original 2012 tax bills which were listed in Section A to this statement. Be sure to use the 2012tax bill which is normally paid during 2013.

PLEASE NOTE: Payment information from the Internet or otherwise is not considered acceptable tax billdocumentation . Facilities located in Cook County are required to provide copies of their original second installment tax bill.

Page 10A

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 11Facility Name & ID Number BRIDGEVIEW HEALTH CARE CTR # 0037358 Report Period Beginning: 01/01/2013 Ending: 12/31/2013X. BUILDING AND GENERAL INFORMATION:

A. Square Feet: 53,650 B. General Construction Type: Exterior BRICK Frame Number of Stories

C. Does the Operating Entity? (a) Own the Facility X (b) Rent from a Related Organization. (c) Rent from Completely Unrelated Organization.

(Facilities checking (a) or (b) must complete Schedule XI. Those checking (c) may complete Schedule XI or Schedule XII-A. See instructions.)

D. Does the Operating Entity? X (a) Own the Equipment (b) Rent equipment from a Related Organization. X (c) Rent equipment from Completely Unrelated Organization.

(Facilities checking (a) or (b) must complete Schedule XI-C. Those checking (c) may complete Schedule XI-C or Schedule XII-B. See instructions.)

E. List all other business entities owned by this operating entity or related to the operating entity that are located on or adjacent to this nursing home's grounds(such as, but not limited to, apartments, assisted living facilities, day training facilities, day care, independent living facilities, CNA training facilities, etc.)List entity name, type of business, square footage, and number of beds/units available (where applicable).N/A

F. Does this cost report reflect any organization or pre-operating costs which are being amortized? YES X NOIf so, please complete the following:

1. Total Amount Incurred: 2. Number of Years Over Which it is Being Amortized:

3. Current Period Amortization: 4. Dates Incurred:

Nature of Costs:(Attach a complete schedule detailing the total amount of organization and pre-operating costs.)

XI. OWNERSHIP COSTS: 1 2 3 4

A. Land. Use Square Feet Year Acquired Cost1 NURSING HOME $ 304,000 12 23 TOTALS $ 304,000 3

HFS 3745 (N-4-99) IL478-2471


XI. OWNERSHIP COSTS (continued) B. Building and Improvement Costs-Including Fixed Equipment. (See instructions.) Round all numbers to nearest dollar.

1 2 3 4 5 6 7 8 9 FOR BHF USE ONLY Year Year Current Book Life Straight Line Accumulated

Beds* Acquired Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation4 146 1995 $ 5,092,000 $ 130,564 39 $ 130,564 $ $ 2,420,952 45 56 67 RELATED PARTY 50,018 1,282 35 1,429 147 29,058 78 8

Improvement Type**9 LEASEHOLD IMPROVEMENTS 1991 1,017 32 31.5 32 711 9

10 LEASEHOLD IMPROVEMENTS 1991 2,715 15 2,715 1011 LEASEHOLD IMPROVEMENTS 1992 85,574 2,718 31.5 2,718 59,571 1112 LEASEHOLD IMPROVEMENTS 1993 1,600 51 31.5 51 1,056 1213 LEASEHOLD IMPROVEMENTS 1994 8,141 209 39 209 4,079 1314 1ST FLOOR CENTRAL A/C 1995 1,250 32 39 32 585 1415 CARPET INSTALL 1995 1,303 33 39 33 601 1516 RAIL BUMPER 1995 917 24 39 24 433 1617 INSTALL PRESSURE CONTROL, LOCK & ALARM 1996 5,320 137 39 137 2,406 1718 PAINTING WORK 1996 8,400 215 39 215 3,736 1819 WALL COVERING 1996 1,435 37 39 37 640 1920 FRONT LOBBY/WINDOW, DOOR WORK 1997 2,509 64 39 64 1,056 2021 ELEVATOR REPAIR 1998 2,800 72 39 72 1,143 2122 CONDENCING UNIT 1999 3,824 98 39 98 1,436 2223 DRAPES 1999 5,369 138 39 138 1,986 2324 CARPETING AND VINYL FLOORING 1999 8,540 219 39 219 3,171 2425 DOOR WORK 1999 10,490 269 39 269 3,858 2526 KITCHEN CABINETS 1999 5,832 149 39 149 2,160 2627 TILES 2000 8,855 322 27.5 322 4,322 2728 ELEVATOR REPAIR 2000 4,240 153 27.5 153 1,968 2829 ROD MAIN SEWER 2000 1,100 41 27.5 41 547 2930 DRAPERIES 2001 2,118 7 2,118 3031 RECEPTION DESK/DOOR 2002 9,534 347 27.5 347 3,817 3132 FLOORING / BUMPER GUARDS 2002 11,198 407 27.5 407 4,478 3233 WALLPAPER, BORDER, ARTWORK 2002 42,079 1,530 27.5 1,530 16,612 3334 WIRING, MOTOR 2002 9,224 336 27.5 336 3,696 3435 HANDRAILS & GUARDS 2003 7,811 284 27.5 284 2,970 3536 2003 4,023 134 15 134 3,419 36

*Total beds on this schedule must agree with page 2. See Page 12A, Line 70 for total**Improvement type must be detailed in order for the cost report to be considered complete

HFS 3745 (N-4-99) IL478-2471



1 3 4 5 6 7 8 9Year Current Book Life Straight Line Accumulated

Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation37 ORIENTATION BOARDS 2003 $ 1,752 $ 64 27.5 $ 64 $ $ 669 3738 COIL 2003 806 29 27.5 29 303 3839 ELEVATOR REPAIRS 2003 3,991 145 27.5 145 1,518 3940 WINDOW TREATMENTS 2003 1,672 61 27.5 61 638 4041 LIGHTING & ALARM SYSTEMS 2003 6,701 244 27.5 244 2,551 4142 FLOOR COVERING 2004 888 32 27.5 32 303 4243 CABINETS 2004 2,594 95 27.5 95 898 4344 BOILER 2004 2,574 93 27.5 93 880 4445 VINYL TILE & COVE BASE 2004 1,186 43 27.5 43 407 4546 BRICK MOUNT SIGN 2004 4,317 287 15 287 2,727 4647 PARKING LOT 2004 34,455 2,298 15 2,298 21,831 4748 FIREPROOFING PENTHOUSE ROOF 2005 9,950 362 27.5 362 3,062 4849 SECURITY MONITORS 2005 1,375 50 27.5 50 423 4950 CARPET & VINYL 2005 21,130 768 27.5 768 6,496 5051 NETWORK CABLING 2006 855 31 27.5 31 231 5152 COOLING TOWER REPAIR 2006 3,565 130 27.5 130 969 5253 RANGE GUARD SYSTEM 2006 2,200 80 27.5 80 597 5354 FANS 2006 1,108 40 27.5 40 298 5455 DOORS 2006 1,711 62 27.5 62 463 5556 LANDSCAPING 2006 23,665 1,578 15 1,578 11,835 5657 FIRE DOORS, PANIC DEVICE, CONTROL PANEL 2007 3,676 134 27.5 134 865 5758 ELEVATOR RECALL SYSTEM 2007 28,000 1,018 27.5 1,018 6,575 5859 RETRACTABLE AWNING 2007 3,336 122 27.5 122 788 5960 CABLING OF BUILDING 2007 20,000 727 27.5 727 4,695 6061 VINYL TILE & COVE BASE 2007 30,063 1,093 27.5 1,093 7,059 6162 CONDENSER 2007 1,712 62 27.5 62 401 6263 ELEVATOR REPAIRS 2008 2,275 83 27.5 83 453 6364 FLOOR & WALL TILE 2008 18,201 662 27.5 662 3,614 6465 DOORS 2008 1,645 60 27.5 60 327 6566 BOILER 2008 5,104 185 27.5 185 1,010 6667 DISH TV EQUIPMENT 2009 1,575 57 27.5 57 254 6768 PLUMBING WORK 2009 13,761 500 27.5 500 2,229 6869 SHOWER ROOMS-DRYWALL,CEMENT BOARD,TILE,SINKS 2009 45,476 1,654 27.5 1,654 7,374 6970 TOTAL (lines 4 thru 69) $ 5,700,555 $ 152,746 $ 152,893 $ 147 $ 2,678,043 70

**Improvement type must be detailed in order for the cost report to be considered complete

HFS 3745 (N-4-99) IL478-2471




Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation1 Totals from Page 12A, Carried Forward $ 5,700,555 $ 152,746 $ 152,893 $ 147 $ 2,678,043 12 FIRE ALARM SYSTEM 2009 107,498 3,909 27.5 3,909 17,428 23 DOORS & WINDOWS 2009 4,434 161 27.5 161 718 34 HEATING WORK 2009 9,475 345 27.5 345 1,538 45 TILE & CORRIDOR SIGNAGE 2009 10,786 392 27.5 392 1,748 56 BOILER -RESET CONTROL,CONVECTOR,COMPRESSOR 2010 16,733 608 27.5 608 2,103 67 WALK IN FREEZER-NEW CONDENSOR, DEFROST TIMER 2010 5,300 193 27.5 193 667 78 3RD FLOOR SHOWER ROOM-NEW TILE,WALLS 2010 17,500 636 27.5 636 2,199 89 FRONT DOOR ALARM,SLIDING,ACCESS DOORS,KEY PAD 2010 6,328 230 27.5 230 795 9

10 REPLACE SEWER LINES HALLWAY AND KITCHEN 2010 34,102 1,240 27.5 1,240 4,288 1011 REPAIRS ROOF-PENTHOUSE AND MAIN ROOF 2010 17,080 621 27.5 621 2,148 1112 4TH FLOOR SHOWER ROOM-NEW WATER LINES, TILE 2010 16,782 610 27.5 610 2,110 1213 LOCKER ROOM - TILE, PAINT AND CARPETING 2010 3,068 112 27.5 112 387 1314 PACH PARKING LOT IN THE BACK OF BUILDING 2010 6,400 233 27.5 233 806 1415 INSTALL NEW VINIL TILE IN THE BACK HALLWAY 2010 4,124 150 27.5 150 519 1516 CABINETS,COUNTERTOP FOR KITCHEN,NEW FLOOR TILE 2010 5,691 207 27.5 207 716 1617 CEILING PIPING 2010 2,825 103 27.5 103 356 1718 AIR HANDLERS,HOT WATER COILS,MOTOR STARTER 2010 12,660 460 27.5 460 1,591 1819 FIRE ALARM WORK, 72 SPRINKLER HEADS 2010 4,249 155 27.5 155 536 1920 DVR RECORD,MONITOR, 2CAMERAS IN PARKING LOT 2010 2,500 91 27.5 91 315 2021 BRICK WALL REPAIR 2010 2,900 105 27.5 105 363 2122 DISH NETWORK SERVICE WORK, SECURITY SYSTEM 2010 3,450 125 27.5 125 432 2223 INSTALL NEW PIPE IN LAUNDRY ROOM 2010 1,850 67 27.5 67 232 2324 REHAB ROOM - ELECTRIC WORK 2010 1,546 56 27.5 56 194 2425 PLUMBING WORK, NEW DRAIN LINE IN KITCHEN AREA 2010 6,275 228 27.5 228 789 2526 NEW RELAY ON COMPRESSOR,WATER TOWER MOTOR 2010 2,653 96 27.5 96 332 2627 AIR CONDITIONING SYSTEM REPAIR 2010 1,735 63 27.5 63 218 2728 THERAPY ROOM - FLOORING 2011 13,166 479 27.5 479 1,177 2829 THERAPY ROOM - WALLCOVERING/CEILING TILE 2011 19,219 699 27.5 699 1,718 2930 THERAPY ROOM - ELECTRICAL WORK 2011 10,134 368 27.5 368 905 3031 THERAPY ROOM - PLUMBING WORK 2011 22,879 832 27.5 832 2,045 3132 THERAPY ROOM - DOORS 2011 12,009 437 27.5 437 1,074 3233 THERAPY ROOM - INSTL OFFICES,FLOORING,DOORS 2011 65,023 2,364 27.5 2,364 5,812 3334 TOTAL (lines 1 thru 33) $ 6,150,928 $ 169,121 $ 169,268 $ 147 $ 2,734,302 34


HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 12CFacility Name & ID Number BRIDGEVIEW HEALTH CARE CTR # 0037358 Report Period Beginning: 01/01/2013 Ending: 12/31/2013



Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation1 Totals from Page 12B, Carried Forward $ 6,150,928 $ 169,121 $ 169,268 $ 147 $ 2,734,302 12 ROOF DRAINS 2011 5,150 187 27.5 187 460 23 SHOWER ROOM FLOOR,DRAIN,TILE 2011 30,945 1,125 27.5 1,125 2,766 34 ROOF REPAIR 2011 5,920 215 27.5 215 529 45 SECURITY/FIRE SYSTEM REPAIR 2011 8,320 303 27.5 303 745 56 COMPRESSOR INSTALL REPAIR 2011 18,703 680 27.5 680 1,672 67 SCANNER 2011 35,598 1,294 27.5 1,294 3,181 78 FLOORING/TACKBOARD/LIGHT fixtures 2011 2,809 102 27.5 102 252 89 9

10 1011 1112 1213 RELATED PARTY - LANDLORD: 1314 COVE BASE, FLOORING 2002 64,984 860 39 860 39,774 1415 HANDRAILS, BUMPERS, CORNER GUARDS 2002 56,219 744 39 744 34,409 1516 WALLCOVERING,BORDER,MOLDING,WINDOW TREATME 2002 125,676 1,663 39 1,663 76,921 1617 CLOSET DOORS & TRACKS 2002 39,288 520 39 520 24,047 1718 LIGHTING, CEILING TILES 2002 38,204 506 39 506 23,384 1819 NURSE STATION 2002 17,320 229 39 229 10,600 1920 ASPHALT PAVING 2002 57,615 4,409 15 4,409 50,704 2021 PATIO, FENCING, ROOFING 2002 20,804 275 39 275 12,732 2122 NURSE STATION 2004 27,559 707 39 707 6,687 2223 CARPET, TILE, WALLCOVERING 2004 42,388 39 42,388 2324 MODERNIZE ELEVATORS 2007 175,828 4,508 39 4,508 29,114 2425 WINDOWS 2006 83,000 2,128 39 2,128 12,679 2526 2627 DOORS & WINDOWS 2012 4,075 153 27.5 153 221 2728 PLUMBING WORK 2012 11,639 433 27.5 433 627 2829 SPRINKLER & FIRE SYSTEM WORK 2012 26,504 968 27.5 968 1,408 2930 FLOORING 2012 8,640 306 27.5 306 450 3031 SECURITY SYSTEM WORK 2012 5,130 178 27.5 178 264 3132 ROOF REPAIR 2012 1,595 51 27.5 51 77 3233 NURSE CALL SYSTEM WORK 2012 1,488 51 27.5 51 76 3334 TOTAL (lines 1 thru 33) $ 7,066,329 $ 191,716 $ 191,863 $ 147 $ 3,110,469 34


HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 12DFacility Name & ID Number BRIDGEVIEW HEALTH CARE CTR # 0037358 Report Period Beginning: 01/01/2013 Ending: 12/31/2013



Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation1 Totals from Page 12C, Carried Forward $ 7,066,329 $ 191,716 $ 191,863 $ 147 $ 3,110,469 12 CEILING REPAIR 2012 2,145 76 27.5 76 112 23 ELECTRIC WORK 2012 2,825 102 27.5 102 149 34 HANDRAIL SPACERS 2012 2,800 102 27.5 102 149 45 CYLINDER FOR ELEVATOR & HEAT MOTOR 2012 3,208 127 27.5 127 181 56 SPRINKLER & SECURITY SYSTEM 2013 13,953 236 27.5 236 236 67 DOORS & HARDWARE 2013 6,459 112 27.5 112 112 78 BATHROOM SINKS, FAUCETS & DRYWALL 2013 15,179 249 27.5 249 249 89 OFFICE WALL REPAIR 2013 4,383 75 27.5 75 75 9

10 AC REPAIR & ROOF FAN INSTALL 2013 8,750 149 27.5 149 149 1011 COMPRESSORS, BREAKERS HEAT COIL 2013 21,983 360 27.5 360 360 1112 WALK IN FREEZER REPAIR 2013 1,055 12 27.5 12 12 1213 FENCE INSTALL 2013 2,800 53 27.5 53 50 1314 1415 1516 1617 1718 1819 1920 2021 2122 2223 2324 2425 2526 2627 2728 2829 2930 3031 3132 3233 3334 TOTAL (lines 1 thru 33) $ 7,151,869 $ 193,369 $ 193,516 $ 147 $ 3,112,303 34


HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 13Facility Name & ID Number BRIDGEVIEW HEALTH CARE CTR # 0037358 Report Period Beginning: 01/01/2013 Ending: 12/31/2013XI. OWNERSHIP COSTS (continued)

C. Equipment Costs-Excluding Transportation. (See instructions.) Category of 1 Current Book Straight Line 4 Component Accumulated Equipment Cost Depreciation 2 Depreciation 3 Adjustments Life 5 Depreciation 6

71 Purchased in Prior Years $ 564,555 $ 15,689 $ 56,455 $ 40,766 10 YRS $ 319,791 7172 Current Year Purchases 75,718 43,438 7,572 (35,866) 10 YRS 7,572 7273 Fully Depreciated Assets 224,113 224,113 7374 RELATED PARTY 26,530 266 845 579 24,078 7475 TOTALS $ 890,916 $ 59,393 $ 64,872 $ 5,479 $ 575,554 75

D. Vehicle Costs. (See instructions.)*1 Model, Make Year 4 Current Book Straight Line 7 Life in Accumulated

Use and Year 2 Acquired 3 Cost Depreciation 5 Depreciation 6 Adjustments Years 8 Depreciation 976 RELATED PARTY $ 26,575 $ 809 $ 5,687 $ 4,878 $ 12,381 7677 7778 7879 7980 TOTALS $ 26,575 $ 809 $ 5,687 $ 4,878 $ 12,381 80

E. Summary of Care-Related Assets 1 2Reference Amount

81 Total Historical Cost (line 3, col.4 + line 70, col.4 + line 75, col.1 + line 80, col.4) + (Pages 12B thru 12I, if applicable) $ 8,373,360 8182 Current Book Depreciation (line 70, col.5 + line 75, col.2 + line 80, col.5) + (Pages 12B thru 12I, if applicable) $ 253,571 8283 Straight Line Depreciation (line 70, col.7 + line 75, col.3 + line 80, col.6) + (Pages 12B thru 12I, if applicable) $ 264,075 83 **84 Adjustments (line 70, col.8 + line 75, col.4 + line 80, col.7) + (Pages 12B thru 12I, if applicable) $ 10,504 8485 Accumulated Depreciation (line 70, col.9 + line 75, col.6 + line 80, col.9) + (Pages 12B thru 12I, if applicable) $ 3,700,238 85

F. Depreciable Non-Care Assets Included in General Ledger. (See instructions.) G. Construction-in-Progress1 2 Current Book Accumulated

Description & Year Acquired Cost Depreciation 3 Depreciation 4 Description Cost86 $ $ $ 86 92 $ 9287 87 93 9388 88 94 9489 89 95 $ 9590 9091 TOTALS $ $ $ 91 * Vehicles used to transport residents to & from

day training must be recorded in XI-F, not XI-D.

** This must agree with Schedule V line 30, column 8.

HFS 3745 (N-4-99) IL478-2471


XII. RENTAL COSTSA. Building and Fixed Equipment (See instructions.) 1. Name of Party Holding Lease: N/A 2. Does the facility also pay real estate taxes in addition to rental amount shown below on line 7, column 4? If NO, see instructions. YES NO 00

001 2 3 4 5 6

Year Number Original Rental Total Years Total YearsConstructed of Beds Lease Date Amount of Lease Renewal Option*

Original 10. Effective dates of current rental agreement:3 Building: $ 3 Beginning4 Additions 4 Ending5 56 6 11. Rent to be paid in future years under the current7 TOTAL $ 7 rental agreement:

** 8. List separately any amortization of lease expense included on page 4, line 34. Fiscal Year Ending Annual Rent This amount was calculated by dividing the total amount to be amortized by the length of the lease . 12. /2014 $

13. /2015 $ 9. Option to Buy: YES NO Terms: * 14. /2016 $

B. Equipment-Excluding Transportation and Fixed Equipment. (See instructions.) 15. Is Movable equipment rental included in building rental? YES NO 16. Rental Amount for movable equipment: $ 6,915 Description: SEE SCHEDULE ATTACHED

(Attach a schedule detailing the breakdown of movable equipment)C. Vehicle Rental (See instructions.)

1 2 3 4Model Year Monthly Lease Rental Expense

Use and Make Payment for this Period * If there is an option to buy the building,17 ADMINISTRATOR 2010 LEXUS $ 600.00 $ 6,824 17 please provide complete details on attached18 PAYROLL ADJ (5,411) 18 schedule.19 1920 20 ** This amount plus any amortization of lease21 TOTAL $ 600.00 $ 1,413 21 expense must agree with page 4, line 34.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 15Facility Name & ID Number BRIDGEVIEW HEALTH CARE CTR # 0037358 Report Period Beginning: 01/01/2013 Ending: 12/31/2013XIII. EXPENSES RELATING TO CERTIFIED NURSE AIDE (CNA) TRAINING PROGRAMS (See instructions.)

A. TYPE OF TRAINING PROGRAM (If CNAs are trained in another facility program, attach a schedule listing the facility name, address and cost per CNA trained in that facility.)

1. HAVE YOU TRAINED CNAs YES 2. CLASSROOM PORTION: 3. CLINICAL PORTION: DURING THIS REPORT PERIOD? X NO IN-HOUSE PROGRAM IN-HOUSE PROGRAM

IN OTHER FACILITY IN OTHER FACILITY If "yes", please complete the remainder of this schedule. If "no", provide an COMMUNITY COLLEGE HOURS PER CNA explanation as to why this training was not necessary. HOURS PER CNA

THE FACILITY HIRES ONLY CERTIFIED NURSES AIDES

B. EXPENSES C. CONTRACTUAL INCOMEALLOCATION OF COSTS (d)

In the box below record the amount of income your1 2 3 4 facility received training CNAs from other facilities.

FacilityDrop-outs Completed Contract Total $

1 Community College Tuition $ $ $ $2 Books and Supplies D. NUMBER OF CNAs TRAINED3 Classroom Wages (a)4 Clinical Wages (b) COMPLETED5 In-House Trainer Wages (c) 1. From this facility6 Transportation 2. From other facilities (f)7 Contractual Payments DROP-OUTS8 CNA Competency Tests 1. From this facility9 TOTALS $ $ $ $ 2. From other facilities (f)

10 SUM OF line 9, col. 1 and 2 (e) $ TOTAL TRAINED

(a) Include wages paid during the classroom portion of training. Do not include fringe benefits. (e) The total amount of Drop-out and Completed Costs for(b) Include wages paid during the clinical portion of training. Do not include fringe benefits. your own CNAs must agree with Sch. V, line 13, col. 8.(c) For in-house training programs only. Do not include fringe benefits. (f) Attach a schedule of the facility names and addresses(d) Allocate based on if the CNA is from your facility or is being contracted to be trained in of those facilities for which you trained CNAs. your facility. Drop-out costs can only be for costs incurred by your own CNAs.

HFS 3745 (N-4-99) IL478-2471


XIV. SPECIAL SERVICES (Direct Cost) (See instructions.)1 2 3 4 5 6 7 8

Schedule V Staff Outside Practitioner SuppliesService Line & Column Units of Cost (other than consultant) (Actual or) Total Units Total Cost

Reference Service Units Cost Allocated) (Column 2 + 4) (Col. 3 + 5 + 6)1 Licensed Occupational Therapist 39-3 hrs $ $ $ $ 1

Licensed Speech and Language2 Development Therapist 39-3 hrs 1,870 1,870 23 Licensed Recreational Therapist hrs 34 Licensed Physical Therapist 39-3 hrs 45 Physician Care visits 56 Dental Care visits 67 Work Related Program hrs 78 Habilitation hrs 8

# of9 Pharmacy 39-2 prescrpts 113,193 113,193 9

Psychological Services (Evaluation and Diagnosis/

10 Behavior Modification) hrs 1011 Academic Education hrs 1112 Other (specify): 12

13 Other (specify): Supplies, Lab, Radiology,Other 25,594 25,594 13

14 TOTAL $ $ 1,870 $ 138,787 $ 140,657 14

NOTE: This schedule should include fees (other than consultant fees) paid to licensed practitioners. Consultant fees should be detailed on Schedule XVIII-B. Salaries of unlicensed practitioners, such as CNAs, who help with the above activities should not be listed on this schedule.

HFS 3745 (N-4-99) IL478-2471


XV. BALANCE SHEET - Unrestricted Operating Fund. As of 12/31/2013 (last day of reporting year) This report must be completed even if financial statements are attached.

1 2 After 1 2 After Operating Consolidation* Operating Consolidation*

A. Current Assets C. Current Liabilities1 Cash on Hand and in Banks $ 218,509 $ 1 26 Accounts Payable $ 537,451 $ 262 Cash-Patient Deposits 2 27 Officer's Accounts Payable 27

Accounts & Short-Term Notes Receivable- 28 Accounts Payable-Patient Deposits 283 Patients (less allowance (335,000) ) 1,790,237 3 29 Short-Term Notes Payable 294 Supply Inventory (priced at ) 4 30 Accrued Salaries Payable 321,332 305 Short-Term Investments 5 Accrued Taxes Payable6 Prepaid Insurance 156,208 6 31 (excluding real estate taxes) 32,359 317 Other Prepaid Expenses 49,136 7 32 Accrued Real Estate Taxes(Sch.IX-B) 372,000 328 Accounts Receivable (owners or related parties) 8 33 Accrued Interest Payable 2,388 339 Other(specify): RE TAX ESCROW 313,507 9 34 Deferred Compensation 34

TOTAL Current Assets 35 Federal and State Income Taxes 3510 (sum of lines 1 thru 9) $ 2,527,597 $ 10 Other Current Liabilities(specify):

B. Long-Term Assets 36 DUE TO BANK LEUMI 750,000 3611 Long-Term Notes Receivable 11 37 LOAN PAYABLE 46,932 3712 Long-Term Investments 12 TOTAL Current Liabilities13 Land 13 38 (sum of lines 26 thru 37) $ 2,062,462 $ 3814 Buildings, at Historical Cost 14 D. Long-Term Liabilities15 Leasehold Improvements, at Historical Cost 1,260,965 15 39 Long-Term Notes Payable 3916 Equipment, at Historical Cost 864,385 16 40 Mortgage Payable 4017 Accumulated Depreciation (book methods) (1,113,467) 17 41 Bonds Payable 4118 Deferred Charges 18 42 Deferred Compensation 4219 Organization & Pre-Operating Costs 19 Other Long-Term Liabilities(specify):

Accumulated Amortization - 43 4320 Organization & Pre-Operating Costs 20 44 4421 Restricted Funds 21 TOTAL Long-Term Liabilities22 Other Long-Term Assets (specify): 22 45 (sum of lines 39 thru 44) $ $ 4523 Other(specify): Deposit 556,627 23 TOTAL LIABILITIES

TOTAL Long-Term Assets 46 (sum of lines 38 and 45) $ 2,062,462 $ 4624 (sum of lines 11 thru 23) $ 1,568,510 $ 24

47 TOTAL EQUITY(page 18, line 24) $ 2,033,645 $ 47TOTAL ASSETS TOTAL LIABILITIES AND EQUITY

25 (sum of lines 10 and 24) $ 4,096,107 $ 25 48 (sum of lines 46 and 47) $ 4,096,107 $ 48

*(See instructions.)

HFS 3745 (N-4-99) IL478-2471


XVI. STATEMENT OF CHANGES IN EQUITY1

Total1 Balance at Beginning of Year, as Previously Reported $ 1,966,218 12 Restatements (describe): 23 ILLINOIS REPLACEMENT TAX (8,263) 34 45 56 Balance at Beginning of Year, as Restated (sum of lines 1-5) $ 1,957,955 6

A. Additions (deductions):7 NET Income (Loss) (from page 19, line 43) 258,090 78 Aquisitions of Pooled Companies 89 Proceeds from Sale of Stock 9

10 Stock Options Exercised 1011 Contributions and Grants 1112 Expenditures for Specific Purposes 1213 Dividends Paid or Other Distributions to Owners (182,400) 1314 Donated Property, Plant, and Equipment 1415 Other (describe) 1516 Other (describe) 1617 TOTAL Additions (deductions) (sum of lines 7-16) $ 75,690 17

B. Transfers (Itemize):18 1819 1920 2021 2122 2223 TOTAL Transfers (sum of lines 18-22) $ 2324 BALANCE AT END OF YEAR (sum of lines 6 + 17 + 23) $ 2,033,645 24 *

* This must agree with page 17, line 47.

HFS 3745 (N-4-99) IL478-2471


XVII. INCOME STATEMENT (attach any explanatory footnotes necessary to reconcile this schedule to Schedules V and VI.) All required classifications of revenue and expense must be provided on this form, even if financial statements are attached. Note: This schedule should show gross revenue and expenses. Do not net revenue against expense.

1 2I. Revenue Amount II. Expenses Amount

A. Inpatient Care A. Operating Expenses1 Gross Revenue -- All Levels of Care $ 8,817,212 1 31 General Services 1,313,453 312 Discounts and Allowances for all Levels ( ) 2 32 Health Care 3,564,651 323 SUBTOTAL Inpatient Care (line 1 minus line 2) $ 8,817,212 3 33 General Administration 2,523,356 33

B. Ancillary Revenue B. Capital Expense4 Day Care 4 34 Ownership 1,015,008 345 Other Care for Outpatients 5 C. Ancillary Expense6 Therapy 314,031 6 35 Special Cost Centers 140,657 357 Oxygen 7 36 Provider Participation Fee 328,070 368 SUBTOTAL Ancillary Revenue (lines 4 thru 7) $ 314,031 8 D. Other Expenses (specify):

C. Other Operating Revenue 37 OUT-OF-PERIOD EXPENSES (11,334) 379 Payments for Education 9 38 38

10 Other Government Grants 10 39 3911 CNA Training Reimbursements 1112 Gift and Coffee Shop 12 40 TOTAL EXPENSES (sum of lines 31 thru 39)* $ 8,873,861 4013 Barber and Beauty Care 1314 Non-Patient Meals 14 41 Income before Income Taxes (line 30 minus line 40)** 258,090 4115 Telephone, Television and Radio 1516 Rental of Facility Space 16 42 Income Taxes 4217 Sale of Drugs 1718 Sale of Supplies to Non-Patients 18 43 NET INCOME OR LOSS FOR THE YEAR (line 41 minus line 42) $ 258,090 4319 Laboratory 1920 Radiology and X-Ray 20 III. Net Inpatient Revenue detailed by Payer Source21 Other Medical Services 21 44 Medicaid - Net Inpatient Revenue $ 4,490,112 4422 Laundry 22 45 Private Pay - Net Inpatient Revenue 1,480,964 4523 SUBTOTAL Other Operating Revenue (lines 9 thru 22)$ 23 46 Medicare - Net Inpatient Revenue 2,552,823 46

D. Non-Operating Revenue 47 Other-(specify) HOSPICE/INSURANCE/ETC 293,313 4724 Contributions 24 48 Other-(specify) 4825 Interest and Other Investment Income*** 708 25 49 TOTAL Inpatient Care Revenue (This total must agree to Line 3) $ 8,817,212 4926 SUBTOTAL Non-Operating Revenue (lines 24 and 25) $ 708 26

E. Other Revenue (specify):**** * This must agree with page 4, line 45, column 4.27 Settlement Income (Insurance, Legal, Etc.) 27 ** Does this agree with taxable income (loss) per Federal Income28 28 Tax Return? YES If not, please attach a reconciliation.

28a 28a *** See the instructions. If this total amount has not been offset against interest29 SUBTOTAL Other Revenue (lines 27, 28 and 28a) $ 29 expense on Schedule V, line 32, please include a detailed explanation.

30 TOTAL REVENUE (sum of lines 3, 8, 23, 26 and 29) $ 9,131,951 30 ****Provide a detailed breakdown of "Other Revenue" on an attached sheet.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 20Facility Name & ID Number BRIDGEVIEW HEALTH CARE CTR # 0037358 Report Period Beginning: 01/01/2013 Ending: 12/31/2013XVIII. A. STAFFING AND SALARY COSTS (Please report each line separately.) (This schedule must cover the entire reporting period.) B. CONSULTANT SERVICES

1 2** 3 4 1 2 3# of Hrs. # of Hrs. Reporting Period Average Number Total Consultant Schedule VActually Paid and Total Salaries, Hourly of Hrs. Cost for Line &Worked Accrued Wages Wage Paid & Reporting Column

1 Director of Nursing $ $ 1 Accrued Period Reference2 Assistant Director of Nursing 1,965 2,243 82,825 36.93 2 35 Dietary Consultant $ 0 1-3 353 Registered Nurses 10,074 11,572 372,838 32.22 3 36 Medical Director 48 2,100 9-3 364 Licensed Practical Nurses 31,680 36,162 996,606 27.56 4 37 Medical Records Consultant 0 10-3 375 CNAs & Orderlies 89,556 103,089 1,080,032 10.48 5 38 Nurse Consultant 0 10-3 386 CNA Trainees 6 39 Pharmacist Consultant 96 9,199 10-3 397 Licensed Therapist 10,890 11,545 494,153 42.80 7 40 Physical Therapy Consultant 0 10a-3 408 Rehab/Therapy Aides 8 41 Occupational Therapy Consultant 0 10a-3 419 Activity Director 5,202 6,057 121,077 19.99 9 42 Respiratory Therapy Consultant 0 10a-3 42

10 Activity Assistants 16,627 18,374 218,718 11.90 10 43 Speech Therapy Consultant 0 10a-3 4311 Social Service Workers 11 44 Activity Consultant 17 816 11-3 4412 Dietician 12 45 Social Service Consultant 0 12-3 4513 Food Service Supervisor 13 46 Other(specify) SPECIAL CARE UNI 104 7,785 10-3 4614 Head Cook 14 47 4715 Cook Helpers/Assistants 15 48 4816 Dishwashers 1617 Maintenance Workers 5,543 5,863 103,473 17.65 17 49 TOTAL (lines 35 - 48) 265 $ 19,900 4918 Housekeepers 1819 Laundry 1920 Administrator 2,037 2,437 129,282 53.05 2021 Assistant Administrator 21 C. CONTRACT NURSES22 Other Administrative 22 1 2 323 Office Manager 23 Number Schedule V24 Clerical 11,864 13,741 265,405 19.31 24 of Hrs. Total Line &25 Vocational Instruction 25 Paid & Contract Column26 Academic Instruction 26 Accrued Wages Reference27 Medical Director 27 50 Registered Nurses $ 10-3 5028 Qualified MR Prof. (QMRP) 28 51 Licensed Practical Nurses 10-3 5129 Resident Services Coordinator 29 52 Certified Nurse Assistants/Aides 10-3 5230 Habilitation Aides (DD Homes) 3031 Medical Records 1,999 2,465 48,231 19.57 31 53 TOTAL (lines 50 - 52) $ 5332 Other Health Care(specify) 3233 Other(specify) 3334 TOTAL (lines 1 - 33) 187,437 213,548 $ 3,912,640 * $ 18.32 34

* This total must agree with page 4, column 1, line 45. ** See instructions.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 21Facility Name & ID Number BRIDGEVIEW HEALTH CARE CTR # 0037358 Report Period Beginning: 01/01/2013 Ending: 12/31/2013XIX. SUPPORT SCHEDULES A. Administrative Salaries Ownership D. Employee Benefits and Payroll Taxes F. Dues, Fees, Subscriptions and Promotions

Name Function % Amount Description Amount Description AmountMARTHA PECK ADMINISTRATOR $ 91,782 Workers' Compensation Insurance $ 102,871 IDPH License Fee $ 2,690FRED AARON ADMINISTRATIVE 37,500 Unemployment Compensation Insurance 84,500 Advertising: Employee Recruitment 8,950

FICA Taxes 294,558 Health Care Worker Background Check 980Employee Health Insurance 192,381 (Indicate # of checks performed 90 )Employee Meals 0 Patient Background Checks 0 Illinois Municipal Retirement Fund (IMRF)* TRUST/FRANCHISE/CONTRIB/ETC 5,615 EMPLOYEE BENEFITS - OTHER 36,157 MARKETING/ADV/PROMO 83,165

TOTAL (agree to Schedule V, line 17, col. 1) LICENSES/DUES/SUBSCRIPTIONS 14,044(List each licensed administrator separately.) $ 129,282 MGMT CO ALLOC 1,268B. Administrative - Other TRUST/FRANCHISE/CONTRIB/ETC (5,615)

Less: Public Relations Expense ( 0 ) Description Amount Non-allowable advertising (83,165) MANAGEMENT FEES $ 186,000 Yellow page advertising ( 0 )

TOTAL (agree to Schedule V, $ 710,467 TOTAL (agree to Sch. V, $ 27,932 line 22, col.8) line 20, col. 8)

TOTAL (agree to Schedule V, line 17, col. 3) $ 186,000 E. Schedule of Non-Cash Compensation Paid G. Schedule of Travel and Seminar**(Attach a copy of any management service agreement) to Owners or EmployeesC. Professional Services Description Amount Vendor/Payee Type Amount Description Line # Amount

$ $ Out-of-State Travel $

In-State Travel0

MGMT CO ALLOC 969

Seminar Expense0

SEE SCHEDULE ATTACHED 80,175 Entertainment Expense ( )TOTAL (agree to Schedule V, line 19, column 3) TOTAL $ (agree to Sch. V,(If total legal fees exceed $5,000, attach copy of invoices.) $ 80,175 TOTAL line 24, col. 8) $ 969

* Attach copy of IMRF notifications **See instructions.

HFS 3745 (N-4-99) IL478-2471


XIX-H. SUPPORT SCHEDULE - DEFERRED MAINTENANCE COSTS (which have been included in Sch. V, line 6, col. 3). (See instructions.)

1 2 3 4 5 6 7 8 9 10 11 12 13Month & Year Amount of Expense Amortized Per Year

Improvement Improvement Total Cost UsefulType Was Made Life FY2007 FY2008 FY2009 FY2010 FY2011 FY2012 FY2013 FY2014 FY2015

1 $ $ $ $ $ $ $ $ $ $23456789

1011121314151617181920 TOTALS $ $ $ $ $ $ $ $ $ $

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 23Facility Name & ID Number BRIDGEVIEW HEALTH CARE CTR # 0037358 Report Period Beginning: 01/01/2013 Ending: 12/31/2013XX. GENERAL INFORMATION:

(1) Are nursing employees (RN,LPN,NA) represented by a union? YES (13) Have costs for all supplies and services which are of the type that can be billed tothe Department, in addition to the daily rate, been properly classified

(2) Are there any dues to nursing home associations included on the cost report? YES in the Ancillary Section of Schedule V? YESIf YES, give association name and amount. ICLTC $ 9,965

(14) Is a portion of the building used for any function other than long term care services for(3) Did the nursing home make political contributions or payments to a political the patient census listed on page 2, Section B? NO For example,

action organization? YES If YES, have these costs is a portion of the building used for rental, a pharmacy, day care, etc.) If YES, attachbeen properly adjusted out of the cost report? YES a schedule which explains how all related costs were allocated to these functions.

(4) Does the bed capacity of the building differ from the number of beds licensed at the (15) Indicate the cost of employee meals that has been reclassified to employee benefitsend of the fiscal year? NO If YES, what is the capacity? on Schedule V. $ 0 Has any meal income been offset against

related costs? N/A Indicate the amount. $(5) Have you properly capitalized all major repairs and equipment purchases? YES

What was the average life used for new equipment added during this period? 10 YR (16) Travel and Transportationa. Are there costs included for out-of-state travel? NO

(6) Indicate the total amount of both disposable and non-disposable diaper expense If YES, attach a complete explanation.and the location of this expense on Sch. V. $ 8,802 Line 10-2 b. Do you have a separate contract with the Department to provide medical transportation for

residents? NO If YES, please indicate the amount of income earned from such a(7) Have all costs reported on this form been determined using accounting procedures program during this reporting period. $

consistent with prior reports? YES If NO, attach a complete explanation. c. What percent of all travel expense relates to transportation of nurses and patients? 5%d. Have vehicle usage logs been maintained? NO

(8) Are you presently operating under a sale and leaseback arrangement? NO e. Are all vehicles stored at the nursing home during the night and all otherIf YES, give effective date of lease. times when not in use? NO

f. Has the cost for commuting or other personal use of autos been adjusted(9) Are you presently operating under a sublease agreement? YES X NO out of the cost report? YES

g. Does the facility transport residents to and from day training? NO(10) Was this home previously operated by a related party (as is defined in the instructions for Indicate the amount of income earned from providing such

Schedule VII)? YES NO X If YES, please indicate name of the facility, transportation during this reporting period. $ N/AIDPH license number of this related party and the date the present owners took over.

(17) Has an audit been performed by an independent certified public accounting firm? NOFirm Name:

(11) Indicate the amount of the Provider Participation Fees paid and accrued to the Departmentduring this cost report period. $ 328,070 (18) Have all costs which do not relate to the provision of long term care been adjusted outThis amount is to be recorded on line 42 of Schedule V. out of Schedule V? YES

(12) Are there any salary costs which have been allocated to more than one line on Schedule V (19) If total legal fees are in excess of $5,000, have legal invoices and a summary of servicesfor an individual employee? NO If YES, attach an explanation of the allocation. performed been attached to this cost report? YES

Attach invoices and a summary of services for all architect and appraisal fees.

HFS 3745 (N-4-99) IL478-2471

Documents

HFS 3745 (N-4-99) IL478-2471€¦ · 10 ICF 21,786 6,493 916 29,195 10 11 ICF/DD 11 IV. ACCOUNTING BASIS 12 SC 12 MODIFIED 13 DD 16 OR LESS 13 ACCRUAL X CASH* CASH* 14 TOTALS 30,134